15-PD 1.1 Attachment E- Pharmacy Vendor Response Workbook.xlsx
XLSX spreadsheet 183 KB Posted
- Attached to
- Health and Pharmacy Benefits
- Solicitation number
- RFP 26-008
- Issued by
- Williamson County, San Antonio City, Texas
About this file
This is a Pharmacy Benefits Manager (PBM) Response Workbook for the City of Round Rock, Texas, seeking proposals for prescription drug claims administration services. The City represents approximately 1,050 covered lives and is currently served by incumbent vendor UnitedHealthcare (UHC) effective January 1, 2027. The RFP was launched on April 1, 2026, with vendor questions due by April 17, 2026, responses provided by April 28, 2026, and proposals due approximately May 1, 2026. The City will complete its review by May 19, 2026, followed by finalist meetings and interviews at undetermined dates, with implementation beginning September 1, 2026, and the plan effective date of January 1, 2027. The contract will have an initial three-year term with potential renewal options. The City's selection criteria, ranked by priority, are financial savings (network discounts, dispensing fees, rebates, drug mix management, and clinical fees); robust clinical strategies (utilization management, clinical offerings, formulary management, specialty drug management, and therapeutic interchange); service (account management, call center, performance metrics, issue resolution, and communications); alignment and transparency (aligned incentives, ease of contracting, legal compliance, and integration); administrative capabilities (plan design flexibility, network options, and mail and specialty capabilities); and technology (adjudication platform autonomy).
The City's current pharmacy plan statistics include 2,225 total members with an average age of 30 years, 2,200 annual prescription claims, and $7.5 million in annual gross pharmacy spend. Vendors must confirm compliance with extensive financial and operational requirements including a one-time Data Warehouse Charge of $15,000 and an ongoing Consulting Fee of $3.25 per member per month (PMPM) to be paid to Holmes Murphy & Associates, the City's consultant. All proposed financial guarantees—including discounts, dispensing fees, administrative fees, and rebate guarantees—must be plan-specific, not book-of-business averages, and guaranteed for the full contract period. The workbook requires vendors to provide detailed pricing across multiple channels (retail 30-day, extended day supply/90-day, mail order, and specialty pharmacy) with specific discount percentages, dispensing fees, and rebate guarantees for brand and generic drugs. Vendors must also offer performance guarantees with mutually agreed-upon weighting that address implementation, ongoing operations, call center metrics, claims processing accuracy, and system availability. The City requires pass-through pricing models with 100% rebate passthrough to the Plan Sponsor and comprehensive audit rights including review of 75% of rebate revenue or 10 pharmaceutical manufacturer contracts. The City reserves the right to conduct annual market checks and has termination for convenience provisions with no early termination fees or penalties.
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Cover
Plan Sponsor Pharmacy Benefits Manager RFP Workbook
Instructions:
Every tab in the workbook is required to be complete as part of the Pharmacy Benefits Manager RFP.
Enter your responses in the highlighted cells provided in each tab of the Workbook.
Do NOT edit the formatting of the tabs in any way; if you edit the formatting of the tabs your response will not be considered.
Confidentiality:
This Pharmacy Benefits Manager RFP Workbook should represent all of the information that you will need to prepare your proposal, including census data and claims experience. This information is considered confidential and should not be shared with anyone outside of your organization.
Intro & Instructions
| INTRODUCTION, GENERAL INFORMATION AND SPECIFIC REQUIREMENTS | |
| 1 | INTRODUCTION |
| Company Overview |
City of Round Rock is a municipal government located in Central Texas, providing essential public services including public safety, public works, utilities, parks and recreation, and community development. As part of the Greater Austin metropolitan area, the City of Round Rock supports a diverse public-sector workforce dedicated to delivering high-quality services to its residents. For this engagement, the City of Round Rock represents an employee population of approximately 1,050 lives and seeks scalable, compliant, and service-focused solutions to support the benefits needs of its workforce.
Corporate Address 221 East Main Street Round Rock, TX 78664
| 2 | PHARMACY PLAN STATISTICS | |
| Incumbent PBM | UHC | |
| Plan Effective Date | 1/1/27 | |
| Total Members on Plan | 2,225 | |
| Average Age of Plan Membership | 30 | |
| Annual Number of Prescription Claims | 2,200 | |
| Annual Gross Pharmacy Spend | $7.5M | |
| 3 | SELECTION CRITERIA | |
| Vendors will be scored, and finalists will be selected based on their ability to service Client's core beliefs (ranked): | ||
| 1. Financial Savings: Network Discounts, Dispensing Fees, Rebates, Drug Mix Mgmt, Clinical Fees |
2. Robust Clinical Strategies: UM Rigor, Clinical Offering, Formulary Mgt/Efficiency, Specialty Drug Mgt, Therapeutic Interchange
3. Service: Account Management, Call Center, Performance Metrics, Issue Resolution, Communications
4. Alignment/Transparency: Aligned Incentives, Ease of Contracting, Legal/Compliance, Integration
5. Administrative: Plan Design Flexibility, Network Options, Mail and Specialty Capabilities
6. Technology: Adjudication Platform Autonomy tc={C2A5736F-9F49-4E34-B15B-85921B0F3031}: [Threaded comment]
Your version of Excel allows you to read this threaded comment; however, any edits to it will get removed if the file is opened in a newer version of Excel. Learn more: https://go.microsoft.com/fwlink/?linkid=870924
Comment:
| Feel Free to remove if not needed. | RFP TIMELINE | 3/1 Launch | 4/1 Launch | |
| RFP finalized and released to market | 4/17/26 | |||
| Vendor Questions regarding the RFP Submission | 4/28/26 | |||
| City of Round Rock provides responses to Vendor Questions | Approx. 5/1/2026 | |||
| RFP Due Date | 5/19/26 | |||
| City of Round Rock completes review of RFP responses | TBD | |||
| Solicit BAFOs from finalists and send finalist meeting agenda | TBD | |||
| Finalist Meetings | TBD | |||
| Review of BAFOs and finalist interview scores | TBD | |||
| Recommendation to Plan Sponsor's Executive Leadership Team | TBD | |||
| Final Decision | TBD | |||
| Implementation Begins | 9/1/26 | |||
| Plan Effective Date | 1/1/27 | |||
| 5 | RFP EXAMINATION & CONFIDENTIALITY | |||
| The respondent is expected to examine this RFP carefully, understand the terms and conditions for providing the pertinent services and respond completely in the format provided. All information included in this RFP is considered confidential and should not be shared with anyone outside of your organization. All reference herein to Client includes their employees and their representatives, specifically Holmes Murphy & Associates. | ||||
| 6 | CONTACT & COMMUNICATION | |||
| During the period between proposal submission and the contract award, the respondent shall not directly discuss or promote their proposal with Client unless requested by Client. No publicity or news release about this RFP, the response, or discussion of any kind related to this RFP, or to the award of any contract, may be released without the prior written approval of Client. | ||||
| 7 | RESERVATION OF RIGHTS | |||
| Client reserves the right to: |
- Reject any and all proposals received
- Issue a subsequent RFP
- Cancel the entire RFP
- Remedy technical errors in the RFP process
- Negotiate with any, all or none of the respondents to the RFP
- Accept the written proposal as on offer
- Waive informalities and irregularities
- Accept one or more proposals Release of this RFP does not commit Client to enter into a contract nor does it obligate it to pay any costs incurred in preparation and submission of proposals or in anticipation of a contract.
| 8 | PROPOSAL SUBMISSION REQUIREMENTS |
| All tabs in highlighted in red are to be completed by the respondent. Instructions for completion are located at the top of each tab. Only requested exhibits or supplemental documentation will be reviewed. Any supplemental information or exhibits provided, not requested by Holmes Murphy, will NOT be reviewed and will NOT be considered part of your complete response. | |
| 9 | Ongoing Consulting Fee |
| 1 | Should your firm be selected as the winning vendor, your offer must include, meaning underwritten into the P&L of your proposal, an ongoing consulting fee of $3.25 per member per month (PMPM) to be paid a monthly basis, beginning upon implementation of the business to: |
Holmes, Murphy and Associates, LLC Attn Operating Account PO Box 441 Des Moines IA 50301
Feel Free to remove if not needed.
Rx Questionnaire
| FINANCIAL QUESTIONS |
| For consistency in the RFP please "confirm" all questions below or state why the deviation. If you fail to "Confirm" all questions, your proposal maybe returned with no further evaluation or consideration. |
| Definitions | Response | Clarification/Explanation (if needed) | |
| 1 | "340B Claim(s)" means a claim that receives 340B program pricing and is dispensed from a 340B program covered entity. 340B claims are identified by the submission of "20" in the Submission Clarification Code (SCC) field (420-DK) AND includes a covered entity owned pharmacy 340B status coded as "38", or "39" in the NCPDP DataQ database. | Please Select | |
| 2 | "Average Wholesale Price" or "AWP" means the average wholesale unit price for a product on the date the product is dispensed as set forth from the most current pricing information provided to PBM by Medispan Prescription Guide including supplements multiplied by the fill quantity. For determining the AWP, the actual 11-digit NDC package size dispensed on the date the product is dispensed will be used. | Please Select | |
| 3 | "Authorized Generic" means a drug that is marketed, sold or distributed in the United States as a Generic Drug version of a Brand Drug where the authority for such marketing, sale and or distribution is based upon a Manufacturer's New Drug Application (NDA) or Biologic License Application (BLA) for the associated Brand Drug and that is marketed, sold or distributed under a different labeler code, product code, trade name, trademark, or packaging (other than repacking the listed drug for use in institutions) than the Brand Drug. | Please Select | |
| 4 | Your organization agrees that for all financial guarantees, Authorized Generics shall be defined as all drugs and supplies with a valid NDC and identified using Medi-Span Multisource Code of "M" (co-branded product) with a Brand Drug Code of "B" (Branded Generic Name). | Please Select | |
| 5 | "Brand Drug" or "Brand Product" means an FDA approved drug, or a drug that is designated by the FDA, a DESI (Drug Efficacy Study Implementation) drug, or product, which is manufactured and distributed by an innovator drug company, or its licensee. | Please Select | |
| 6 | Your organization agrees that for all financial guarantees, Brand Drugs shall be defined as all drugs and supplies with a valid NDC and identified using the following criteria: |
1. Brand Name code of "T" and Multisource Code of "M"
2. Brand Name code of "T" or "B" and Multisource Code of "N"
3. Brand Name code of "T" or "B" and Multisource Code of "O" and a DAW code of 0,1,2,7,8 or 9.
For avoidance of doubt, Brand Products include, but are not limited to: vaccines, supplies, medical devices, kits, diabetic supplies, OTCs and test strips.
| Unless explicitly outlined in these financial requirements, once a product has been deemed a Brand Product it must be considered a Brand Product for purposes of all financial measurements, including, but not limited to, AWP discounts, dispensing fees, and rebate sharing arrangements. | Please Select | |||
| 7 | "Biosimilar Drug" or "Biosimilar Product" means a biological product that is highly similar to a US-licensed reference biological product notwithstanding minor differences in clinically inactive components, and for which there are no clinically meaningful differences between the biological product and the reference product in terms of safety, purity, and potency of the product as defined in the Biologics Price Competition and Innovation Act of 2009 at. 42 U.S.C 262(i)(2) and approved under Section 351(k) of the Public Health Services Act and as identified in the Purple Book. | Please Select | ||
| 8 | "Claims approved by Formulary Exception" means a claim that was ultimately approved for coverage, (by client override, exception, medical necessity, or appeal) where otherwise, is standardly excluded from the formulary. | Please Select | ||
| 9 | "Compound Drug" shall mean a mixture of two or more ingredients when at least one of the ingredients in the preparation is an FDA approved federal legend drug, and the mixture of which is not otherwise generally available in an equivalent commercial form or strength in response to a physician's prescription to create a medication tailored to the specialized medically required need for an individual patient. A Compound Drug is identified by the compound indicator on the claim feed. | Please Select | ||
| 10 | "Coordination of Benefits" or "COB Claim(s)" means a claim where more than one health insurance program, policy, or other form of coverage, including governmental or non-governmental coverage, and the Plan Sponsor acts as a secondary or tertiary payor for the claim. | Please Select | ||
| 11 | "Covered Drug(s)" or "Covered Product(s)" means those prescription drugs, supplies, Specialty Drugs, OTC products, non-drug products, and other drugs/products that are covered under the Plan. | Please Select | ||
| 12 | "Generic drug or Generic Product" means an FDA approved drug, or a drug that is designated by the FDA a DESI (Drug Efficacy Study Implementation) drug, or product, that is therapeutically equivalent to other pharmaceutically equivalent products. | Please Select | ||
| 13 | Your organization agrees that for all financial guarantees, Generic Products shall be defined as all drugs and supplies with a valid NDC and identified using the following criteria: |
1. Multisource Code of "Y"
2. Brand Name code of "G" for all Multisource Codes of (M,N,O, and Y)
3. Multisource code of "M" and a Brand Drug Code of "B" (Authorized Generic)
4. Multisource Code of "O" with a DAW code of 3, 4, or 6
5. Multisource Codes of M,N,O, or Y and a DAW code of 5 (House Generic)
For avoidance of doubt, Generic Products include, but are not limited to: vaccines, supplies, medical devices, kits, diabetic supplies, OTCs and test strips.
| Unless explicitly outlined in these financial requirements, once a product has been deemed a Generic Product it must be considered a Generic Product for purposes of all financial measurements, including, but not limited to, AWP discounts, dispensing fees, and rebate sharing arrangements. | Please Select | |||
| 14 | "Home Infusion Pharmacy" or "HIF" means a Retail Pharmacy-based, decentralized patient care organization with expertise in USP 797-compliant sterile drug compounding that provides care to patients with acute or chronic conditions generally pertaining to parenteral administration of drugs, biologics, and nutritional formulae administered through catheters and/or needles in home and alternate sites. These Pharmacies are identified by a National Council for Prescription Drug Program's (NCPDP's) dispenser type code of 6. | Please Select | ||
| 15 | "House Generic Drug" means a Brand Drug submitted with a Dispense as Written (DAW) 5 code in place of the Generic Drug equivalent and where the pharmacy is reimbursed at the Generic Drug rate, including MAC, as applicable. For reconciliation of the Generic Drug discount guarantees, the AWP of the House Generic drugs shall be the per unit AWP of the Generic Drug equivalent and not the AWP of the Brand Drug. House Generics will be identified using Medispan Multisource Code of M, N, O or Y and a DAW code of 5. | Please Select | ||
| 16 | "Indian Health Services, Tribal or Urban Indian Health" or "I/T/U" means a Retail Pharmacy operated by the Indian Health Service, and Indian tribe or tribal organization, or an urban Indian organization as defined in Section 4 of the Indian Health Care Improvement Act, 25 U.S.C. 1603. These Pharmacies are identified by a National Council for Prescription Drug Program's (NCPDP's) dispenser type code of 8. | Please Select | ||
| 17 | "Individual Pricing Component" means each individual combination of pricing guarantee (ex. discount, dispensing fee, rebate etc.), dispensing channel (ex. Retail, Mail Order, Specialty Pharmacy etc.), and drug status (ex. Brand Drug, Generic Drug, Specialty Drug etc.) as applicable. | Please Select | ||
| 18 | "In-House Pharmacy" or "Onsite Pharmacy" means a Retail Pharmacy that is owned, licensed, operated or identified by PBM, where the Participating Pharmacy is operating on Client’s campus for use by its Members. | Please Select | ||
| 19 | "Limited Distribution Specialty Drugs" or "Limited Distribution Specialty Products" are those Specialty Drugs only available through select pharmacy providers as determined by the drug manufacturer. | Please Select | ||
| 20 | “Limited Supply Generic” or “Short Supply Generic” means a generic not available in sufficient supply in the marketplace. The drug shortages may be caused by many factors, including difficulties in acquiring raw materials, manufacturing problems, regulatory issues, and business decisions, as well as many other disturbances within the supply chain. Generic drugs will be deemed as Limited or in Short Supply if listed on the FDA or the American Society of Health-System Pharmacists (ASHP) Drug Shortages websites. | Please Select | ||
| 21 | "Long Term Care Pharmacy" or "LTC" means a Retail Pharmacy that dispenses medicinal preparations delivered to patients residing within an intermediate or skilled nursing facility, including intermediate care facilities for mentally disabled, hospice, assisted living facilities, group homes, and other forms of congregate living arrangements. These Pharmacies are identified by a National Council for Prescription Drug Program's (NCPDP's) dispenser type code of 4. | Please Select | ||
| 22 | "Mail Order Pharmacy" or "Mail" means one or more duly licensed pharmacies specified by PBM as where Covered Products are filled and delivered to members via mail service. | Please Select | ||
| 23 | “Maintenance Drug” means any drug that contains a maintenance medication indicator as provided in a nationally recognized drug information source (e.g., Medi-Span or First Databank). Maintenance Drugs are utilized with plan designs that include a mandatory mail or retail 90-day programs that charge a penalty after a set number of retail fills. | Please Select | ||
| 24 | “Maximum Allowable Cost” or “MAC” means the maximum allowable cost per unit charged to Plan Sponsor by PBM for a drug on the date dispensed, subject to the pricing set forth on the then-current MAC List. | Please Select | ||
| 25 | "MAC List" means the list established and maintained by PBM of off patent drugs subject to MAC pricing and their corresponding unit prices. Each such unit price shall be specified by National Drug Code (“NDC”), Generic Code Number ("GCN") or Generic Product Identifier ("GPI") and include the dates for which such price was in effect. | Please Select | ||
| 26 | "Military Pharmacy" means a Retail Pharmacy whose primary function is to store, prepare and dispense pharmaceuticals and other associated items to uniformed services beneficiaries. These pharmacies may be associated with Department of Defense or U.S. Coast Guard clinic, Department of Defense hospital or freestanding. These Pharmacies are identified by a National Council for Prescription Drug Program's (NCPDP's) dispenser type code of 17. | Please Select | ||
| 27 | “Multi-Source Generic” means a Generic Drug that is available from two or more pharmaceutical manufacturers. | Please Select | ||
| 28 | "New-To-Market" means drugs that have only been available for purchase on the U.S market for 180 days or less, from the FDA's approval date | Please Select | ||
| 29 | "Outlier Claim" means a Brand Drug Claim with an AWP discount equal to or greater than 30.000001% and the undiscounted AWP Ingredient Cost is greater than $1,000; and a Generic Drug Claim with an AWP discount equal to or greater than 98.000001% and the undiscounted AWP Ingredient Cost is greater than $1,000. Notwithstanding the foregoing, Brand Drug Claims and Generic Drug Claims documented on the Specialty Drug Pricing List that meet these Outlier Claim requirements shall not constitute an Outlier Claim | Please Select | ||
| 30 | "Over-the-Counter Claim(s)" or "OTC Claims" means a claim for items that do not require a prescription for a member to purchase that the Plan Sponsor has chosen to or has been required to include as Covered Products under the prescription drug benefit. OTC Claims are defined as having an 'O' or 'P' indication in Medispan's Rx-OTC Indicator Code. | Please Select | ||
| 31 | "Pass-Through Pricing” means a pricing model whereby PBM will bill the Plan Sponsor the same amount paid to the Participating Pharmacy under its contracted arrangement with such Participating Pharmacy at cost with no additional mark-up, and PBM receives no other revenue and derives no other value from any paid claim adjudicated at the Participating Pharmacy, either directly or indirectly, in the aggregate or otherwise, except for the fee(s) charged by PBM to a Participating Pharmacy for administrative services related to dispensing Covered Products to members. | Please Select | ||
| 32 | "Participating Pharmacy" means a Retail Pharmacy, Mail Order Pharmacy, Specialty Pharmacy, non-traditional pharmacy (ex. I/T/U, LTF, HIF, Military, TER, or VA) or other pharmacy that participates in the PBMs network pursuant to an agreement between the Participating Pharmacy and PBM to dispense Covered Products to Plan Sponsor's members. | Please Select | ||
| 33 | “Patent Litigation Drug” means a Covered Product under patent litigation within the United States court system between the drug innovator and a generic pharmaceutical company. | Please Select | ||
| 34 | "PBM" means the pharmacy benefit manager submitting this bid in response to Plan Sponsor’s request for proposals for pharmacy benefits administration services. | Please Select | ||
| 35 | "Plan " means the Plan Sponsor's prescription drug benefit plan administered by PBM under this bid. | Please Select | ||
| 36 | "Plan Sponsor" means the entity that has issued this invitation to PBM to submit a Bid to provide services under the Plan. | Please Select | ||
| 37 | "Rebate(s)" will be defined as all revenue received from aggregators, third parties, or pharmaceutical manufacturers including, but not limited to, rebates, manufacturer administrative fees, inflation protection payments, outcomes based contracting, educational payments, data payments, reimbursements, and other fees or compensation paid, credited, or owing to, collected and/or received by your organization, affiliates and/or subsidiaries which are related to the Plan Sponsor's utilization. Rebates also include reimbursements or payments from rebate aggregators, group purchasing organizations or pharmaceutical manufacturers connected to rebates, manufacturer administration fees, inflation or price increase protection arrangements. | Please Select | ||
| 38 | "Rebate Guarantee" means the minimum Rebate per Brand Drug by dispensing channel. The performance will be calculated for the annual period using the following formula for each dispensing channel independently, then summed. 'The calculation of the Annual Rebate Guarantee Amount will be the sum of [Rebate Guarantee] multiplied by [total Brand Drug count minus the exclusions as outlined below] for each dispensing channel. | Please Select | ||
| 39 | "Retail Pharmacy" or "Retail" means any chain or independent duly licensed pharmacy where a Covered Product may be filled and provided to a member. | Please Select | ||
| 40 | "Single Source Generic(s)" or "SSGs" are Generic Drugs that are manufactured by one pharmaceutical manufacturing company. | Please Select | ||
| 41 | "Specialty Drug" or "Specialty Product" means The product must require a customized medication management program that includes medication use review, patient training, coordination of care and adherence management for successful use such that more frequent monitoring and training may be required and must meet at least one of the following four characteristics: |
1. Produced through DNA technology or biological processes
2. Target chronic or complex disease
3. Route of administration could be inhaled, infused, oral or injected
| 4. Unique handling, distribution and/or administration requirements | Please Select | ||||||||
| 42 | In addition, a follow-on-biologic or generic product will be considered a Specialty Drug if the innovator drug is a Specialty Drug and meets the criteria above. | Please Select | |||||||
| 43 | Confirm that the classification of a product as Specialty will be consistent for all pricing terms and guarantees, including but not limited to discounts, dispensing fees, and rebates. A product that is deemed to be specialty for one pricing component, such as AWP discounts, must be considered specialty for all other pricing components, inclusive of rebates. | Please Select | |||||||
| 44 | All drugs and/or products that do not meet the above Specialty Drug criteria will be dispensed via mail at the standard Mail Order pricing rates (i.e., discounts, dispensing fees, and rebate guarantees or via retail at the standard retail rates (i.e., discounts, dispensing fees, and rebate guarantees). | Please Select | |||||||
| 45 | "Specialty Pharmacy" means one or more duly licensed pharmacies where prescriptions for Specialty Drugs are dispensed and delivered to members. | Please Select | |||||||
| 46 | "Specialty Product List" means the list(s) of Specialty Products and reimbursement rates applicable to claims for Specialty Products dispensed at a PBM Specialty Pharmacy and/or Retail Pharmacies, as indicated on the list. The Specialty Product List is maintained and, with notice to the Plan Sponsor, updated by PBM from time to time in order to add new-to-market drugs, reasonably determined to be Specialty Products, improve pricing on existing Specialty Products, and to remove drugs from the list. The Specialty Product List(s) applicable to the plan shall be provided to Plan Sponsor in an electronic file format upon request. | Please Select | |||||||
| 47 | "Territory Pharmacy" or "TER" means a Retail Pharmacy located in one of the United States territories (i.e.. American Samoa, Guam, Northern Mariana Islands, Puerto Rico, US Virgin Islands). These pharmacies are identified by an ISO 3166 (state code) of AS, GU, MP, PR, and VI. | Please Select | |||||||
| 48 | "Traditional Pricing" or "Spread-Pricing" means a financial structure comprised of fixed guaranteed discounts and fees. In this arrangement, PBM retains the difference between contracted rates with Participating Pharmacies and the rates guaranteed to Plan Sponsor. Contracted rates with Participating Pharmacies may vary and PBM may realize positive margin when amounts paid to Participating Pharmacies is less than the amount billed to Plan Sponsor. Conversely, PBM may realize negative margin when amounts paid to Participating Pharmacies is greater than the amount billed to Plan Sponsor. | Please Select | |||||||
| 49 | "Usual and Customary Price(s)" or "U&C(s)" means the cash price available to the general public as submitted by the Retail Pharmacy for a claim on the date such claims is dispensed. These shall include all applicable customer discounts including but not limited to: generic promotions, special customer, senior citizen, frequent shopper, discount club, discount card program, etc. A U&C claim is one in which the claim is adjudicated at the U&C price and always has a dispensing fee of $0.00. | Please Select | |||||||
| 50 | "Vaccine Claim(s)" means a claim in which the dispensed produced is a preparation used as a preventative inoculation to confer immunity against a specific disease, usually employing an innocuous form, fragment, toxin, or DNA of the disease agent to stimulate antibody production, and for which the purchase price includes the ingredient cost, dispensing fee, the vaccine fee and the vaccine administration fee. The claims are identified with the Medispan Generic Product ID (GPI-2) or '17' or '18'. | Please Select | |||||||
| 51 | "Veteran Affairs Pharmacy" or "VA" means a retail pharmacy under veteran affairs jurisdiction where drugs are dispensed and pharmaceutical care is provided to enrolled veterans, by licensed pharmacists. VA pharmacies are identified by the National Council for Prescription Drug Program's (NCPDP) dispenser type code of 9. | Please Select | |||||||
| 52 | "Zero Balance Due" or "ZBD Claim(s)" means any claim where the member pays the total amount of the claim including any applicable sales tax and the Plan Sponsor pays zero. | Please Select | |||||||
| General Business Requirements | Response | Clarification/Explanation (if needed) | |||||||
| 53 | Per the Procurement Requirements, your organization has read and agrees to pay the required one-time Data Warehouse Charge of $15,000, to be underwritten into the P&L of your proposal. Refusing this requirement will disqualify your proposal. | Please Select | |||||||
| 54 | Per the Procurement Requirements, your organization has read and agrees to pay the required ongoing Consulting Fee of $3.25 per Member per Month (PMPM), to be underwritten into the P&L of your proposal. For all retail Pass-through pricing arrangements, this fee must be incorporated into your proposed Administrative Fee. Refusing this requirement will disqualify your proposal. | Please Select | |||||||
| 55 | Your organization will serve the Plan Sponsor with an experienced account team that can provide daily operational and clinical support and strategic planning and analysis. | Please Select | |||||||
| 56 | Your organization will provide quarterly and annual plan management reporting to the Plan Sponsor [and to consultant, and this reporting will include sufficient information for the Plan Sponsor to understand the performance of their plan. | Please Select | |||||||
| 57 | Your organization will maintain formal business continuity and disaster recovery plans during the term of the agreement, and will provide a copy of these to the Plan Sponsor upon request. | Please Select | |||||||
| 58 | Your organization will provide claims-level utilization data monthly to Plan Sponsor and at least five of Plan Sponsor's vendors (ex. data warehouse, stop loss, consultant, disease management provider, etc.) in electronic format via FTP, secure email, or other accessible format, at no additional charge. | Please Select | |||||||
| 59 | Your organization will not implement or administer any program that results in the therapeutic switching of members from lower net cost products to higher net cost products without the prior written consent of the Plan Sponsor. Your organization will outline all additional costs associated with such a program in the pricing section of this RFP. | Please Select | |||||||
| 60 | Confirm your ability to match the current plan design(s) as listed in the Plan Design Tabs. | Please Select | |||||||
| 61 | Confirm your pricing offer is based on a Pass-through model | Please Select | |||||||
| 62 | Confirm your willingness to review and complete necessary pharmacy information required in the SBC. | Please Select | |||||||
| Pricing Questions | Response | Clarification/Explanation (if needed) | |||||||
| 63 | Your responses within this document will supersede any conflicting information that may be presented outside of this template (e.g. pricing supplements, exhibits, etc.) | Please Select | Confirmed | Not Confirmed | Confirmed with Conditions | ||||
| 64 | You must provide an executable contract with your response based on the requirements within this template. | Please Select | |||||||
| 65 | Your proposed financial offer must be based on Plan Sponsor's current plan designs, coverage criteria, clinical programs and will not require implementation of any new programs that are outside of what's currently in place today, nor assume coverage of therapy classes not covered today. | Please Select | Confirmed | ||||||
| 66 | All applicable financial terms (including but not limited to adjudication formulas, AWP discounts, dispensing fees, administrative and clinical program fees, Rebate Guarantees, Specialty Drug discounts, and Specialty Drug dispensing fees) submitted by your organization will be guaranteed as specified for the full contract period and incorporated into the contract. | Please Select | |||||||
| 67 | The financial terms proposed by your organization are Plan Sponsor specific, and not book of business averages or illustrative. | Please Select | |||||||
| 68 | Adjudication for Retail Pharmacy Claims: For each claim processed and dispensed to a member through a Retail Pharmacy, Plan Sponsor shall pay the PBM, the Total Claim Cost less the Member Cost Share plus any applicable administrative fees. The Total Claim Cost is defined as the lowest of: |
(a) The pharmacy contracted discount (Brand Drug) + Dispensing Fee + sales tax;
(b) Maximum Allowable Cost + Dispensing Fee + sales tax;
(c) The pharmacy contracted Non-MAC discount (if applicable) + Dispensing Fee +sales tax;
(d) Usual & Customary amount + sales tax;
| (e) Pharmacy submitted amount + sales tax | Please Select | ||
| 69 | Adjudication for Mail Order Claims: For each claim processed and dispensed to a member through a Mail Order Pharmacy, Plan Sponsor shall pay the PBM, the Total Claim Cost less the Member Cost Share plus any applicable administrative fees. The Total Claim Cost is defined as the lowest of: |
(a) The Brand Drug discount + Dispensing Fee + sales tax;
(b) Maximum Allowable Cost + Dispensing Fee + sales tax;
(c) The pharmacy contracted Non-MAC discount (if applicable) + Dispensing Fee +sales tax;
| (d) Pharmacy submitted amount + sales tax | Please Select | ||
| 70 | Member Cost Share: At the point of sale, members will always pay the lowest of: |
(a) The applicable copayment as defined by the benefit plan,
(b) Usual & Customary price
(c) Pharmacy contracted rate
(d) Maximum Allowable Cost (MAC), if applicable, or
(e) pharmacy submitted price.
| In no event will the Member pay the full copay if the contracted cost or submitted cost is lower than that copay. | Please Select | |||
| 71 | Confirm you will adjudicate multi-ingredient Compound Drug claims using the NCPDP D.0 standard. | Please Select | ||
| 72 | For any Compound Drug claims submitted for reimbursement under the pharmacy benefit plan, you will request a copy of the ingredient list and quantity to verify that the claim has been submitted in accordance with contractual and NCPDP standards. | Please Select | ||
| 73 | You will collect the following elements for each Compound Drug claim from every pharmacy submitting a claim for a Compound Drug: |
(a) Compound Indicator
(b) NDC, Quantity, Submitted ingredient cost for each individual component in the recipe
(c) Total Quantity and the total Usual & Customary price
| (d) Level of Effort value | Please Select | ||
| 74 | Adjudication logic for each NDC in the Compound Drug claim recipe will be processed at the lowest of: |
(a) The AWP minus the Brand Drug discount;
(b) The AWP minus the non-MAC discount;
(c) MAC (if applicable); or,
(d) The dispensing pharmacy’s submitted price.
| The lowest adjudicated price for each ingredient in the Compound Drug claim recipe will be combined to create a Total Compound Drug Claim Cost. | Please Select | ||
| 75 | Plan Sponsor will reimburse you for each Compound Drug claim at the lowest of: |
(a) The Total Compound Drug Claim Cost;
| (b) The pharmacy submitted Total Usual & Customary price; | Please Select | |||||
| 76 | As a standard practice, you will review each and every Compound Drug claim greater than $200 and complete an audit of the recipe when claims appear aberrant. | Please Select | ||||
| 77 | You will review all pharmacies that submitted a Compound Drug claim quarterly to be measured against peer groups to control for fraud, waste and abuse. | Please Select | ||||
| 78 | MAC pricing will be applied to all pricing channels, including (if applicable) retail, 90-day retail maintenance, specialty pharmacy and mail order channels. The MAC pricing list and discounts applied on mail order and 90-day retail maintenance claims will be as competitive as or more competitive than the MAC pricing applied through the proposed 30-day Retail network. | Please Select | ||||
| 79 | All Claims with a days supplied filled for >34 days will be included in the pricing guarantee reconciliation for the Retail 90 channel, including discounts, dispensing fees and minimum Rebate guarantees. | Please Select | ||||
| 80 | Please confirm that all proposed "effective" discounts and the discount guaranteed price calculation excludes the following claim types: | Please select how each allowable claim type will be priced (select from dropdown) | Confirmed with conditions | |||
| a. | Reversed/Rejected Claims | Please Select | Please Select | |||
| b. | Compound Claims | Please Select | Please Select | |||
| c. | 340B Claims | Please Select | Please Select | |||
| d. | Member Submitted (Paper) Claims | Please Select | Please Select | |||
| e. | Secondary Payer/COB Claims | Please Select | Please Select | |||
| f. | Claims filled at a Military Pharmacy or Veterans Affairs Pharmacy | Please Select | Please Select | |||
| g. | Vaccine Claims | Please Select | Please Select | |||
| h. | Plan Sponsor owned/affiliated pharmacy claims (if applicable) | Please Select | Please Select | |||
| 81 | Please confirm that all claims filled in Most Favored Nation states are INCLUDED in discount guarantees. | Please Select | ||||
| 82 | Please confirm that all claims filled in rural pharmacies are INCLUDED in discount guarantees. | Please Select | ||||
| 83 | For the avoidance of doubt, all claims not specifically outlined above as excluded will be INCLUDED in the calculation of the Individual Pricing Component for purposes of discount and dispensing fee reconciliation. Any additional exclusions listed in the comments section shall be defined for the purposes of the contract. | Please Select | ||||
| 84 | Brand Discount Guarantees. Confirm that will include all Brand products in the Brand Drug discount and dispensing fee guarantee reconciliations. Brand Drugs shall include Single-Source and Multi-Source Brand Drugs. You will not include any Generic Drugs in the Brand Drug discount and dispensing fee guarantee reconciliations. | Please Select | ||||
| 85 | Generic Discount Guarantees. Confirm that you will include all Generic products (including but not limited to, an approved ANDA, Single-Source Generics, Multi-Source Generics, Authorized Generics, Patent Litigation, House Generics, and Generic Products available in Limited Supply) in the overall Generic discount guarantee and dispensing fee reconciliations. Furthermore, you will not include any Multi-Source Brand Drugs where a DAW penalty is assessed in the Generic Drug discount and dispensing fee guarantees for reconciliation. | Please Select | ||||
| 86 | There will be NO dispensing fee applied to the following: | |||||
| a. | U&C Claims | Please Select | ||||
| b. | OTC claims | Please Select | ||||
| c. | Reversed/Rejected Claims | Please Select | ||||
| 87 | Will dispensing fees be applied to the following types of claims? | |||||
| a. | Compound Claims | Please Select | ||||
| b. | Devices | Please Select | ||||
| c. | Vaccines | Please Select | ||||
| d. | Claims filled in Most Favored Nation States | Please Select | ||||
| e. | Split Fill Claims | Please Select | ||||
| 88 | The following financial guarantees will be reconciled annually. | |||||
| a. | Discounts | Please Select | ||||
| b. | Dispensing Fees | Please Select | ||||
| c. | Admin Fees | Please Select | ||||
| d. | Rebates | Please Select | ||||
| 89 | Please indicate which methodology you are proposing for pricing Specialty Drugs: | |||||
| a. | Brand Drug Effective Rate | Please Select | ||||
| b. | Generic Drug Effective Rate | Please Select | ||||
| c. | New to Market Specialty Products | Please Select | ||||
| d. | New to Market Limited Distribution/Exclusive Distribution Specialty Products | Please Select | ||||
| e. | Specialty Drug Level Pricing (Please complete the Rx Pricing Specialty Drugs tab/worksheet) | Please Select | ||||
| f. | Overall Effective Discount (All Specialty Drugs, LTD, NTM Specialty, Generics, Biosimilars) | Please Select | ||||
| 90 | 100% Member Paid Claims (Zero Balance Due Claims) will be calculated based on the ingredient cost before the subtraction of member paid amount. | Please Select | ||||
| 91 | An Administrative fee will only be charged on paid claims (not on rejected or reversed claims). | Please Select | ||||
| 92 | No minimum charges will apply to any claims; there will be no minimum charge at Retail or Mail Order Pharmacies. | Please Select | ||||
| 93 | Please confirm that all proposed minimum Rebate Guarantee calculation excludes the following: | |||||
| a. | Reversed/Rejected Claims | Please Select | ||||
| b. | Compound Drugs, Bulks, Powders | Please Select | ||||
| c. | 340B Claims | Please Select | ||||
| d. | Member Submitted (Paper) Claims older than 180 days | Please Select | ||||
| e. | Secondary Payer/COB Claims | Please Select | ||||
| f. | Claims filled at a Military Pharmacy or a Veterans Affairs Pharmacy | Please Select | ||||
| ERROR:#VALUE! | Vaccine Claims | Please Select | ||||
| g. | 100% Member Cost Share Program Claims | Please Select | ||||
| 94 | For the avoidance of doubt, all claims not specifically outlined above as excluded will be INCLUDED in the calculation of the Rebate Guarantees and the Annual Rebate Guarantee Amount for purposes of reconciliation. Furthermore, Plan Sponsor shall nevertheless receive 100% of all Rebates received by PBM, if any, earned on the noted exclusions above. | Please Select | ||||
| 95 | Confirm that the following classes will not be classified as Specialty Drugs for purposes of pricing and Rebate guarantees: | |||||
| a. | Anti-Nausea Drugs | Please Select | ||||
| b. | Transplant Drugs | Please Select | ||||
| c. | IVIG | Please Select | ||||
| d. | HIV | Please Select | ||||
| e. | Hepatitis B | Please Select | ||||
| f. | PCSK9s | Please Select | ||||
| 96 | Your proposed pricing for Specialty Products, inclusive of AWP Discounts, Dispensing Fees, and Rebates, assumes that the plan allows for a maximum 30 day supply for any such claims (not an average). | Please Select | ||||
| 97 | The inclusion of copay assistance dollars, patient assistance funds, and coupons in the measurement of Rebate Guarantees is not acceptable. Confirm that any monies collected from these programs are not included in the calculation of Rebates, Rebate Credits, and/or Rebate guarantees. | Please Select | ||||
| 98 | 100% of all Rebates, as defined above, which are related to the Plan Sponsor’s utilization, will be paid to the Plan Sponsor. All earned Rebates will be paid out regardless of drug status or classification (ex. Single-Source Brand, Multi-Source Brand, Generic, OTC, etc.). | Please Select | ||||
| 99 | Please confirm if your firm is offering the following type of minimum Rebate Guarantee: | |||||
| a. | Per All Claims | Please Select | ||||
| b. | Per All Brand Drug Claim by dispensing channel | Please Select | ||||
| c. | Per Single Source Brand Drug Claim | Please Select | ||||
| d. | Per Formulary (Preferred) Brand Drug Claim | Please Select | ||||
| e. | Per Employee Per Month (PEPM) | Please Select | ||||
| f. | Per Member Per Month (PMPM) | Please Select | ||||
| 100 | For minimum Rebate Guarantees quoted on a Per All Brand Drug Claim basis, your quote assumes: | |||||
| a. | You will include all Brand claims, including but not limited to single-source brand claims, multi-source brand claims, non-preferred Brand claims, Limited and Exclusive Specialty brand claims, and OTC products and supplies with a brand classification. All Brand Drug claims will be included in the calculation regardless of day supply or member funding percentage. | Please Select | ||||
| b. | The calculation used for each dispensing channel and applicable minimum Rebate Guarantee, will be the summed product of [Total Number of Brand Claims dispensed in each channel minus Brand Claims excluded from each channel as defined by the Exclusions herein] multiplied by [The minimum Rebate Guarantee for that dispensing channel] | Please Select | ||||
| 101 | The minimum Rebate Guarantees provided in your pricing bid account for all reasonably foreseeable patent expirations. The Rebate Guarantees will not be adjusted during the term of the agreement due to expected branded product patent expiration or the availability of new Generic Drugs in the marketplace. | Please Select | ||||
| 102 | For Rebate Guarantees used as an Administrative Services Only (ASO) fee offset, you will pay Plan Sponsor the Rebate Guarantee on the ASO fee invoice immediately following the end of calendar month the Rebate yielding claim was incurred, regardless of whether your firm has invoiced or received Rebates from drug manufacturers. | |||||
| Please Select | ||||||
| 103 | For all other Rebate Guarantee basis, you will pay Plan Sponsor Rebates within sixty (60) calendar days following the end of calendar quarter the Rebate yielding claim was incurred, regardless of whether your firm has invoiced or received Rebates from drug manufacturers. | |||||
| Please Select | ||||||
| 104 | At the year end, PBM will reconcile 100% of earned Rebates against the Rebate Guarantees and provide documentation of the calculation and the result to Plan Sponsor, without written request, within one hundred and twenty (120) calendar days from the end of each contract year | Please Select | ||||
| 105 | PBM will pay Plan Sponsor 100% of the shortfalls resulting from the guarantee reconciliation on a dollar-for-dollar basis (shortfalls may not be limited in any way), without written request, within one hundred fifty (150) calendar days after the end of each contract year. | Please Select | ||||
| 106 | Shortfalls in any pricing guarantee component may not be offset by surpluses in any other guarantees including but not limited to Zero Balance Due, savings associated with utilization management programs, clinical guarantees, Performance Guarantees, DAW penalty amounts, and any other guarantees. The only exception to this is the use of Rebate Credit for reconciliation of minimum Rebate guarantees. | Please Select | ||||
| 107 | With the exception of Rebates, each Individual Pricing Component will be reconciled individually, including those pricing components within channels. No offsetting is allowed. | Please Select | ||||
| 108 | At the year end, PBM will reconcile the Individual Pricing Component guarantees against the actual performance and provide documentation of the calculation and the result to Plan Sponsor, without written request, within sixty (60) calendar days from the end of each contract year | Please Select | ||||
| 109 | As part of the discount, dispensing fee and Rebate reconciliation process, you will provide a copy of the claims file, including Rx Number, that was used to create the reconciliation report and resulting outcome, with Plan Sponsor and Plan Sponsor's third party consultant. | Please Select | ||||
| 110 | PBM will pay Plan Sponsor one hundred percent (100%) of the shortfalls resulting from the guarantee reconciliation on a dollar-for-dollar basis (shortfalls may not be limited in any way), without written request, within ninety (90) calendar days after the end of each contract year. Any surplus value amounts in the reconciliation of discount and dispensing fees will be retained by Plan Sponsor. | Please Select | ||||
| Rebate Credits | Response | Clarification/Explanation (if needed) | ||||
| 111 | Your offer will be based on post 1/1/2026 pricing for drugs in which the Average Manufacturer Price ("AMP") cap due to the Inflation Reduction Act. | Please Select | ||||
| 112 | You may only use a Rebate Credit, or other financial mechanism, to reduce the value of your proposed minimum Rebate Guarantees, when conducting the annual reconciliation of earned Rebates to the minimum Rebate Guarantees, in the year in which the manufacturer reduced their list price, warranting the change. No carryover or reoccurring credit will be allowed in subsequent years. | Please Select | ||||
| Credits and Allowances | Response | Clarification/Explanation (if needed) | ||||
| 113 | Your firm agrees to provide at least $5 Per Member Per Year (PMPY) Pharmacy Management Fund allowance to cover any additional costs incurred either directly through you or external costs related to the administration of Plan sponsor's prescription drug program. | Please Select | ||||
| 114 | Any unused portion of the Pharmacy Management Fund in one period will carry over to the subsequent plan year. | Please Select | ||||
| 115 | Please confirm the following activities are approved uses of the PMF: | |||||
| a. | Clinical Program Fees | Please Select | ||||
| b. | Utilization Management Fees (PAs, QL, Step Therapy) | Please Select | ||||
| c. | Carve-out Fees (ex. third party file feeds/data exchanges) if applicable | Please Select | ||||
| d. | Health Initiatives related to managing complex diseases (ex. Wellness credits) | Please Select | ||||
| e. | Costs associated with SBC, SPD, or any other Rx communication materials | Please Select | ||||
| f. | Rx Consulting Services | Please Select | ||||
| g. | Data warehouse / reporting & analytics implementation and maintenance fees | Please Select | ||||
| Clinical Management | Response | Clarification/Explanation (if needed) | ||||
| 113 | During the contract term, Plan Sponsor shall have the ability to customize or make changes to any of the following programs during the contract period: | |||||
| a. | Prior Authorization | Please Select | ||||
| b. | Step Therapy | Please Select | ||||
| c. | DUR | Please Select | ||||
| d. | Quantity Level Limit | Please Select | ||||
| e. | Therapeutic MAC / Reference Based Pricing | Please Select | ||||
| f. | DAW 1 and DAW 2 Programs | Please Select | ||||
| g. | Formulary | Please Select | ||||
| h. | Plan Design | Please Select | ||||
| i. | Drug Exclusions | Please Select | ||||
| j. | Network status for contracted retail pharmacies | Please Select | ||||
| k. | Non-Essential Health Benefits | Please Select | ||||
| l. | Lifestyle Medications (ex. Cosmetic, weight-loss medications, transgender care etc.) | Please Select | ||||
| 114 | The Plan Sponsor has the ability to customize there Formulary (Change Tier Status of Medications, or exclude Coverage of Medications) knowing that this could result in rebate implications. | Please Select | ||||
| 115 | If Plan Sponsor wished to make changes to the formulary that impact any pricing component in your offer, you will model and agree to Rebate Guarantee changes by amending the contract to reflect the new Rebate Guarantees | Please Select | ||||
| 116 | The Plan Sponsor will not be required to adopt your clinical bundles, but can individually select specific clinical programs within those bundles. | Please Select | ||||
| 117 | Prior Authorization criteria for Specialty Products can be adjusted to accommodate Plan Sponsor request to match an industry best practice or medical center requested protocol. | Please Select | ||||
| 118 | PBM will can support manufacturer copay assistance programs at PBM owned specialty, and the actual patient copayment (removing the manufacturer assistance from the claim) will be reported back to the accumulator as it relates to deductible and out of pocket maximum. If this does not exist today please define how long it would take or other PBM options available. | Please Select | ||||
| 119 | The Plan Sponsor has the ability to carve out specialty management and rebate reporting to another vendor. | Please Select | ||||
| 120 | PBM will exclude all new products to market where appropriate until the appropriate reviews and clinical criteria can be put in place. | Please Select | ||||
| 121 | PBM agrees to work with Plan Sponsor and consultant in actively managing the appropriate drug usage which may include personalized outreach to physicians to educate them on the financial impact of medications that offer no clinical advantage over more affordable alternatives when the plan does not allow exclusions due to plan design or employee rights/union. Example such as the high cost medications from Valeant Pharma, etc. | Please Select | ||||
| 122 | Does your Auto-Refill protocols account for a patient’s existing stockpile of medication on hand for each fill? | Please Select | ||||
| 123 | Confirm you will allow the Plan Sponsor to set their own Auto-Refill protocols including the ability to implement a “Lookback” mechanism that accounts for patients’ supply on hand. | Please Select | ||||
| 124 | Confirm your proposal is not contingent on the Plan Sponsor implementing your standard PBM’s Auto-Refill logic | Please Select | ||||
| Audit Rights | Response | Clarification/Explanation (if needed) | ||||
| 122 | Plan Sponsor (or a mutually agreeable third party agent) will have the right to audit the following aspects ("Audit Scope") of their contractual arrangement with your organization: | |||||
| a. | Performance of the plan against contracted discounts and fees for all claims | Please Select | ||||
| b. | Plan design and benefit setup accuracy | Please Select | ||||
| c. | Eligibility accuracy | Please Select | ||||
| d. | The greater of 75% of Rebate revenue or 10 pharmaceutical manufacturer contracts | Please Select | ||||
| e. | Rebate Credit measurement and calculation | Please Select | ||||
| f. | MAC pricing accuracy and consistency | Please Select | ||||
| g. | Medicare Retiree Drug Subsidy (RDS) eligibility and claims submissions | Please Select | ||||
| h. | Mail Order and Specialty Pharmacy fulfillment accuracy | Please Select | ||||
| i. | Service performance guarantee reporting and calculation | Please Select | ||||
| 123 | Plan Sponsor will not be held responsible for time or miscellaneous costs incurred by your organization in association with an audit including, but not limited to, the costs associated with providing audit reports, systems access or space. | Please Select | ||||
| 124 | Your organization will review and confirm the Audit Scope within thirty (30) calendar days from receipt of the audit notification letter. | Please Select |
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